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1. SKIN INTEGRITY Created by: Ruth Bryant RN, MS, CWOCN Director, webWOC Nursing Education Program Partner, Bryant Rolstad Consultants, LLC Minneapolis, MN REDUCING THE THREATS !

2. Skin Integrity: Reducing the Threats Objectives: 1. Correlate normal skin anatomy with maintaining skin integrity. 2. Describe how the skin protects the body from threats to skin integrity. 3. Describe the threats posed by aging, soap, bathing, dry skin and skin tears. 4. Identify nursing interventions that reduce the threat to skin integrity.

3. Why the Focus on Skin Integrity? • Intact top layer of skin is a barrier from environmental threats. • When skin integrity is altered, the risk of problematic complications such as pressure ulcers and skin infections is increased. • With aging, the skin is less efficient as a barrier and less resilient to environmental threats. • An increasing number of patients will be admitted to our institutions who have a heightened risk for altered skin integrity by virtue of their age.

4. Anatomy of the Skin

5. Skin Integrity: Key Structures of the Skin • Stratum Corneum • Dermis • Basement Membrane Zone (BMZ)

6. Stratum Corneum • Intact stratum corneum is the first line of defense for the body. • The stratum corneum is constantly being replaced and requires an orderly, regulated process of keratinocyte proliferation and differentiation.

7. Dermis • The second layer of the skin. • Contains sebaceous glands. • Predominant proteins are elastin and collagen. • Contains a “ground substance”composed of proteoglycans (PG’s) and glycosaminoglycans (GAG’s)

8. Basement Membrane Zone (BMZ) • Located where the epidermis and dermis meet. • Epidermal surface consists of fingerlike downward projections known as Rete pegs. • Dermal surface consists of upward projections known as Dermal papillae. • Dermal papillae contains numerous capillary loops.

9. Functions of the Skin • Sensation • Metabolism • Thermoregulation • Communication • Protection

10. The Protective Function of the Skin • An intact stratum corneum protects the skin from Fluid and Electrolyte loss. • Capillary loops and dermal proteins assist in retention of moisture in skin.

11. The Protective Function of the Skin • The collagen and elastin present in the dermis protect the skin from Mechanical Injury .

12. The Protective Function of the Skin • Skin pigmentation and the presence of melanin protects the skin from Ultraviolet Radiation.

13. The Protective Function of the Skin • Several characteristics of the skin provide protection from Pathogens: • Intact stratum corneum • Presence of Sebum • Acid pH (4.5-6.5) • Normal skin flora (resident flora) • Skin Immune System

14. Threats to Skin Integrity “Natural” Threats • Aging • Dry Skin “Man-induced” Threats • Skin Tears • Soaps • Conventional Bathing Techniques

15. AGING: Natural Threat to Skin Integrity • Age alters the skin’s ability to retain moisture: • Decrease in dermal proteins. • Decrease in number of capillary loops in basement membrane zone. • Prolonged epidermal turnover.

16. AGING: Natural Threat to Skin Integrity • Age changes that alter skin’s ability to resist pathogens: • Change in the composition of sebum • Decreased number of Langerhan’s cells • Decrease in number of mast cells

17. AGING: Natural Threat to Skin Integrity • Age changes that alter skin’s ability to resist mechanical stresses: • Flattening of Rete ridge and Dermal papillae • Decreased amount of dermal proteins (elastin and collagen) • Decrease in subcutaneous fat

18. DRY SKIN: Natural Threat to Skin Integrity • Affects 75% of people over 64 years of age. • Results from prolonged epidermal turnover. • The “aging” corneocytes in the stratum corneum are less adherent so the barrier function of the skin is compromised. • Less adherent corneocytes create a larger surface area which allows more fluid loss through the skin.

19. SKIN TEARS: Man-Induced Threat to Skin Integrity Risk factors for developing skin tears: • Advanced age • Sensory loss • Impaired nutrition • Impaired cognition • Dependency on staff for ADL’s • Need for mechanical devices

20. SOAPS: Man-Induced Threat to Skin Integrity • Alkaline soaps decrease layers of stratum corneum. • Soaps emulsify lipids. • Soaps remove resident and transient flora. • Alkaline soaps increase skin natural pH. • Soaps may interfere with water holding capacity of the skin.

21. Conventional Bathing Techniques: Man-Induced Threat to Skin Integrity How is bathing a threat to skin integrity? • Basins often remain damp between baths and are therefore a a vehicle for bacterial proliferation and transmission. • The negative effects of hand washing on the integrity of the hands in nurses has been extensively documented. • Basin bathing is analogous to hand washing.

22. Conventional Bathing Techniques: Man-Induced Threat to Skin Integrity What are the negative effects of hand washing? • Changes in resident skin flora. • Heavy skin shedding so protective layer of stratum corneum is compromised. • Broken skin increases the risk of transmission of microorganisms.

23. Conventional Bathing Techniques: Man-Induced Threat to Skin Integrity Frequency Function Form Basin Bathing

24. Basin Bathing Conventional Bathing: Man-Induced Threat to Skin Integrity Alkaline Soaps Force and Friction Washcloths Hot Water

25. How is Alkaline Soap a Threat? • Thins the stratum corneum. • Emulsifies lipids. • Removes resident flora. • Alkalinizes skin pH. • Reduces water holding capacity of skin.

26. How is the Washcloth a Threat? Washcloth material becomes harsh and rough because of frequent laundering in bleach. Washcloth can transmit microorganisms to other body parts during bathing process and contaminate basin and surrounding environment.

27. How is Hot Water a Threat? • Hot water has a drying effect on the skin. • The potable water source can be contaminated. • Bath water can cross-contaminate personnel and environment.

28. How is Force or Friction a Threat? Considerable force and friction is typically used to lather up the cloth and skin. This amount of force or friction on the skin can be abrasive to the stratum corneum.

29. Reducing the Threat to Skin Integrity How can we provide care to the patient, bathe them and still “do no harm” to their skin?

30. Reducing the Threat of Soap Recommendations: • Use soaps with neutral pH. • Avoid detergent based antiseptics. • Eliminate harsh skin care products. • Minimize contact with soap and solvents. • Consider using waterless cleansers. • Use solutions that contain moisturizers. • Use moisturizers during and after cleansing. • Treat dry skin with moisturizers.

31. Reducing the Threat of Washcloths Recommendations: • Use thick soft cloths. Additional Benefits: • Washcloths are a surprisingly costly item in institutions because they must be replaced frequently.

32. Reducing the Threat of Hot Water Recommendations: • Avoid hot water; use slightly warm water and replenish as needed. • Use premoistened cloths that can be warmed. • Explore utilization of new delivery mechanisms for skin cleansing. Additional Benefits: • Warm bath is very soothing and relaxing. • Reduce down time for staff while waiting for tap water to warm up. • A cool bath is uncomfortable and may have a negative effect on thermoregulation.

33. Reducing the Threat of Force & Friction Recommendations: • Pat dry rather than “rubbing and scrubbing”. • Avoid rough skin scrubbers. • Minimize force/friction when bathing.

34. Reducing the Threat to Skin Integrity Additional Recommendations: • Cleanse skin at time of soiling and at routine intervals. • Individualize frequency of bathing according to patient need and preference. (AHRQ, 1992)

35. Reducing the Threat to Skin Integrity:Conclusion Dr. Elaine Larson in 1999 stated that “… traditional hand washing practices warrant re-examination.” With consideration of our ultimate responsibility to the patient to optimize the protective barrier function of the skin, it is reasonable to propose: “Conventional bathing techniques warrant re-examination.”